|Motor control to motor freedom
A recent study published in one of the world’s premier medical journals (The Lancet) on treatment for whiplash using motor control principles has attracted a lot of attention (Michaleff et al 2014). A number of Australia’s best known researchers and clinical physiotherapists were involved in the study. 172 chronic whiplash sufferers (grades 1 and 2) were given a booklet to read and put into two matched groups. One had 20×1 hour sessions of treatments based on motor control principles and graded activity, the other group had a 30 minute educational session during which they read the educational booklet, could ask questions, were given advice to move and were offered two phone call follow ups. Both groups improved but the key finding was that the comprehensive motor control programme was no more effective than the 30 minute educational session. Essentially it doesn’t work for this particular group and probably for other groups in chronic pain.I hope that people see this as a positive result – for patients, researchers, clinicians and for those who pay. These results may well be causing some angst in communities teaching and using the motor control philosophies which have dominated rehabilitation in Australia and elsewhere for the last 20 years. If not it should be as it strikes at the core of current practice and the findings are strong enough to influence practice.Time for personal and professional reflection
Maybe those who had practice foundations based on motor control philosophies can admit they were not quite right. But that takes guts and sometimes a loss of years of clinical mileage which can be hard. Yet most clinicians in practice have had to do it at least once in their professional life. A vast amount of resources over two decades, and more than a little hype have gone into education, research, marketing and promoting the approach. These resources need urgent diversion elsewhere. The 12 month prevalence of chronic pain is around 39% (Tsang and et.al 2008). Chronic pain is more prevalent than heart disease, diabetes and cancer combined (Jensen and Turk 2014). We should move fast. These findings may well lead to a professional redefinition. Maybe the main drivers of this approach could even apologise for hogging the conferences, agenda and research dollars?
There is a tough question that must be asked – Why did we ever think this approach would work? The philosophy of therapy used here assumes that chronic whiplash syndrome with its stigma and inherent biopsychosocial aspects is a motor control issue – as such it is therefore a focus on epiphenomena, on one brain output only, that of altered muscle activity, perhaps an example of pareidolia. Lost in the mass of research motor control minutiae is a simple question – what is the biology of ‘whiplash associated disorders’? A parallel view in existence for 20 years, based essentially on neuroimmune based plasticity and neuropsychology, suggests that reciprocal and adapting perturbations of input, processing and multiple coping systems of which the motor system is just one, should be entertained. In other words, the paradigm of motor control is just not big enough for a disorder such as chronic whiplash.
Time to stop bastardising ‘education’
Nothing so detailed for training in the education group – this was 30 minutes which included reading the handout, answering questions and access to two explanation sessions. We have no information on the core educational competencies of the therapists, or whether they were even aware of and trained to answer the most common questions. Education is belittled – it is as though it is an accepted intervention which we are all competent and equal at!
The booklet itself is a biomedical booklet. It has been known for many years that biomedical styles of education do not help chronic pain states. (Cohen, Goel et al. 1994; Gross, Aker et al. 2000; Maier-Riechle and M. 2001) There is nothing in this booklet on the kind of education which is known to work – that of Explain Pain type education, something with an ‘A’ evidence grading on the National Health and Medical Research Council’s grading, i.e. – “the body of evidence can be trusted to guide clinical practice”. The Explain Pain style of education is not just advice to move or telling someone that the presence of pain may not signify damage, it is explaining the benefits of activity on all systems and it is explaining why ‘hurt’ does not necessarily equal ‘harm’. It is not saying that you have central sensitisation or other nervous system changes, it is explaining how the nervous system has become overly protective and what you can do about it. There are considerable competencies to achieve to be efficient at this form of education. Simply, in chronic pain states there will be multiple causes, structural and motor changes may well be one, but critically the symptomatology and disability depends more on what a person thinks, does, says, believes, who they meet and where they go.
And more bastardisation occurs. A Reuters report of the educational component of the study says it was ‘counselling’. Counsellors should be appalled. We need to get serious about how we define education and how we research it. If the education group in the study considered educational competencies and modern pain biology educational interventions known to work, I hypothesise that the outcomes would be better than that of the 20×1 hour group work. Education based on motor freedom principles may be better and a realisation that that includes immune, linguistic, emotional, cognitive, creative, autonomic and endocrine freedom as well.
Explore the second last line in the Lancet paper – “Last, how to successfully deliver simple advice needs to be established”. Advice is never simple. A Steve Job’s quote comes to mind “Simple can be harder than complex. You have to work hard to get your thinking clean to make it simple. But it’s worth it in the end because once you get there, you can move mountains”. A start would be to use the word ‘curriculum’, something rarely used in our clinics. If you are educating seriously you would have considered the notion of curriculum, both one-on-one or in a group. The word should instantly bring up content, delivery, timing and measurement. Perhaps educational psychology may be a new and better path to follow rather than health psychology.
This review is not a call to ‘down tools’ as has been suggested by one commenter in a lengthy, discussion in response to a Body in Mind blog on the same article. It is not a call to stop healthy expression of movement, but it is a call for urgent change and revision of the paradigms which we work under. It is a call to adapt and alter tools; to use the best evidence from basic sciences and clinical trials to develop new tools, and it is a call for a serious understanding of education as an intervention.
Many thanks to the authors for publishing this and congratulations on the quality of study which made it to one of world’s premier medical journals. This is useful use of taxpayer money if the findings alter and refine research and clinical practice.
– Michaleff ZA, Maher CG, Chung-Wei CL,Rebbeck T, Jull GJ, Latimer J, Connelly L, Sterling M (2014) Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial. The Lancet http://dx.doi.org/10.1016/S0140-6736(14)60457-8
Wow, in the words of the infamous WWE wrestling fan ” Thank you for saying, what needed to be said! “
The history of science has always been one of paradigm shifts. To practise in these times is going to be a privilege.
Nice one David… and I have to agree, a good use of taxpayer funds! ;))
You mention the skill required to do this properly and I absolutely agree. For me the essential skill is in establishing the kind of trust where I can say “Alright, bend forwards to touch your toes, it’s fine you won’t do any damage” and the patient doesn’t even hesitate for a second, but performs the movement with complete abandon. He does this because I said said it was ok (if a similarly qualified colleague was to give the exact same instructions, there would be hesitation, pain, stiffness and after effects). The hardest patients to treat are the ones with the most fear. Trust fixes this.
To establish such trust, I’ve not found a better approach than person-centered therapy. The power of this approach is absolutely mind blowing and extremely hard to practice (I get it right about 1 in 10 attempts). Whilst I never signed up to be a psychologist, I understand now this is essentially what we are, like it or not. I’m growing into it I guess.
I don’t know about “tools down” either. Patients as a whole aren’t yet ready to be that direct and honest… or maybe we aren’t. There’s no need for physical input as far as I can see.
Hi David and noijammers
This is really useful information and reassuring for anyone that has ever
questioned the motor control paradigm and certainly asks big questions
of our profession and where we are going so thanks for that!
One question i have is around explain pain education. You mention
that there are considerable competencies to achieve to be efficient at
this type of education. Could you elaborate on what these competencies
are as i feel this would help health professionals that are trying to
integrate explain pain education into their management approach.
That is a good question. I do have a suggested core competencies outline if you are getting into research but the broad answer is that educationalists will need :
educational “ammunition”, ie the science that makes the stories – the story that the patient receives is the tip of the iceberg
knowledge of the broad paradigms that pain literacy could fit under.
A probable reconceptualization of what pain is (therapist and patient).
the ability to translate knowledge into therapeutic narrative
the ability to alter therapeutic narrative to target “kind” of misconception
an “Explain pain” assessment
Educational science skills
Coaching skills . Hypnosis skills, CBT skills would also be desirable
Happy to elaborate on any of the above.
One competency might sound pretty obvious : a broad knowledge and understanding of neurobiology and pain, however this may be a pitfall
when it comes to education. Because neurobiology can be quite complex and the knowledge base is big, very big.
Maybe Einstein’s quote is of help:
“Everything should be made as simple as possible, but no simpler.”
Totally agree David.
Thank you for this very accurate and SIMPLE words. You move mountains!
Hope to see you in Spain or elsewhere someday soon!
Great summation David. This needs to be said, but more than that all of us need to be a bit more humble about the power we think we have in our hands. Really the true power comes from our abilities to reason and communicate. there is an old Quaker phrase of “speaking truth to power”. Power, however, lies in the truth. Perhaps we do not really know what the truth is. That is yet to be proven. I think we can say with some certainty- we know what the truth ain’t!!!! Take care. TGD
Thanks for this review and interpretation of meaningfulness of findings. Personally, I am sympathetic towards your interpretation. However, there are a few points for accuracy:
1) You say both groups improved when in fact the trial showed that none of the groups achieved ‘clinically worthwhile effects’ . The authors misleadingly and repeatedly report “equal effectiveness”. This is incorrect.
2) At least a half of the 172 subjects did not have an observable motor control dysfunction, but we’re treated for such (in a non-specified way). If this was a drugs trial, it would not have been published.
3) This is a single trial on 172 subjects. Not a review of repeated trials. Thus it has no evidential weighting.
Can you please explain how “these findings may well lead to a professional redefinition”? Especially when “these findings” are from an under-powered single study which has extremely limited external validity and no evidential relevance?
Thanks for your thoughtful comments Roger
I accept your point that the design of the trial does not tell us that both treatments were equally effective, indeed, as you correctly point out both may well have been entirely ineffective.
With regards point 2, I would suggest it is perfectly possible that a drug trial might be approved for an ill-defined syndrome where approaches to characterising underlying mechanistic subgroups are not well established or accepted (such as whiplash). I am not sure how we can quantify how many participants had a motor control dysfunction from the report. I think this argument speaks to the issue of subgrouping. Motor control was just one aspect of the programme and therapists were allowed some freedom to individually tailor treatment to the presenting patient, and it is not clear how we might best identify such a subgroup, if indeed one exists.
On your third point – this is indeed a single trial but I would strongly argue that this does not give it no evidential relevance. We would love a meta-analysis of a collection of similar studies but this is arguably the best trial to date on this topic.
I’ve spoken to a number of people about the strength of this study before and after posting this noinote. I think the power issue is a red herring since there is no apparent trend towards an effect on the primary outcomes. So it would require a trial of ridiculous size to demonstrate an effect if there is one there to be found, which there probably isn’t. A larger trial is not likely to have returned a “better” result. Also the trial was powered to both detect an effect and to look for effect modifiers. Technically it is therefore powered to detect an effect.
I suspect that you might feel that we are over emphasising our position based on a single trial, but I think your position unfairly devalues the information this trial offers. Here we have a trial that I would defend from a methodological standpoint, designed and delivered by a group who buy into the treatment paradigm tested, that is as null as a trial with subjective outcomes and an imbalance of clinical attention is ever likely to be. And that is something worth discussing. Plus when it is put in context with evidence from basic sciences, (“why would this work”) the 20 year license that the motor control groups have had to test their concepts and the simple “what’s happening on the streets” that we educationalist deal with daily, suggests that it’s time for professional redefinition.
I am concerned that you may be suggesting in “evidential weight” that this study should be repeated. There are limited resources in non pharmacological research to repeat the study and if notions of evidential weight include “reason” I think it would be a waste of time and money. It’s time for universities to halt the research machine in this field and redirect precious resources.
By the way, what was it that made you sympathetic to the view I outlined?
Very best wishes
Completely agree that we can be more successful with what we say than a particular specific treatment regime, and its very hard for some to believe that. I am at the moment on the wave of explain pain and long may it continue as its the first wave that I have felt “fits”, but I come off a wave of motor control which has always sat a little too specific in my mind.
I use many different exercises but I I still like pilates as a way to get people to start exercising who wouldn’t before, then I throw in explain pain nuggets during relaxation at the end of a pilates for LBP class, or during individual treatment session. Do not get me wrong I have taken part in classes where the participants seem to feed off the fact they need to do it or they will get pain again, surely not helped by the need to get people paying time and time again, but if taught correctly and without all the negative pain driving discussions surely it can have its place? Its about not being a purist and believing that one regime is the holy grail, but using our variety of skills that fits the patient in front of us? I believe everyone should be try to be active in whichever form this takes, yes the reasoning behind how they work may be rocky, but can I check as long as you are not feeding the dependance with lines like “your core is weak, you have an unstable spine or instability” then does it matter what we use?
I am rather new to this so bare with me if some my thoughts are still a little simplified, but the breathing techniques used in Pilates seem to fit with increasing the parasympathetic drive, the repetitive nature of each conscious “pain free” exercise surely helps with neuroplasticity and developing new neurotags, the fact patients see it as a form of “safe” exercise relieves there fear and anxiety I’m sure helped by the fact its being taught by a physio encoring exercise and movement possibly all helps me see results.
Your thoughts don’t appear at all simple and I feel they reflect high level reasoning. There are many ways/systems to get people moving and while some may need adjustment to reflect current basic and clinical sciences, take the good bits that fit with your thinking. Yes and critically – deal with the situation where too many people have been left with the undeveloped and unexplained “your core is weak” metaphor. (watch the “your glutes are turned off as well!)
Go for it!
My concern here is that a physician may read this article and think, “this means there is nothing physical therapy can do for my patient! May as well just do surgery.” The real problem is that physicians don’t see the value of the biopsychosocial model or its educational paradigms. At least in most of the US this is the case.
All I can comment here is that if physicians are reading such literature (the Lancet paper), they would hopefully be reading similar literature on surgical outcomes which in many cases are not too good either.
There is a problem with physician education in pain treatment. For many, their professional redefinition in this area has not yet begun.
Hi David, and thanks for your response.
From a study design point of view, I am in total agreement that this is a methodologically robust trial, and scores high on any risk-of-bias tool. However, the devil is in the detail. What I meant by comparing with a drug-trial is that it would be hard to justify/publish a trial of say anti-hypertensives on a group of which a proportion did not have hypertension, find a negative result and claim that anti-hypertensives don’t work. However, I do accept that this pragmatic trial did show that people referred to PTs with “whiplash associated disorder” went to their PTs, who did various things, and none of it worked. In this group. And I accept that this result, if true, fits existing data on this issue. In fact, this is the more important issue: that we are starting to see a trend.
I’m not necessarily saying that we should use precious resources to repeat such a trail, but we do seem to get ahead of ourselves sometimes when considering scientific development. We do tend to get over-excited about single trials when we know that most trials are false (http://tinyurl.com/mcmzhh6) and particularly so in high-quality PT trials (http://tinyurl.com/p8udbed) .
We seem to be having the opposite problem to medicine who are constantly striving to get more negative trails published. PT seems to be a-wash with negative trials. If these are robust studies, it is absolutely the case that we take note and jump on the opportunity to review and redefine our understanding , education, and practice. The interpretation of this trial (not just as in your post, but consistently in many responses to this, and other negative PT trials) is typically paradoxical in that we are happy to accept that it was sufficiently powered to detect an effect if there is a negative result. However, if an effect were to be found, we would insist that it was under-powered and call for larger trials. False-negatives and false-positives are equally an issue with small sample sizes (http://www.ncbi.nlm.nih.gov/pubmed/24768005) .
Anyway, you may have noticed that my response to your post is actually nothing more than a pedantic rant on the interpretation of trials. The bigger picture is something I am in agreement with, hence my sympathies to you. There are growing trends from research findings towards redefining how we think about what we thought we knew. This is the only way we can progress. I think we are at an exciting time when the very foundations of many schools of thought/practice (motor control; manual therapy etc etc) are being seriously challenged. I just think we have to be careful about taking negative findings for one theory as being positive proof for another; otherwise we’ll end up in the same boat. Hence I do agree that there should be a critical point when precious resources should be re-directed. And this point is very close.
All the best, and thanks for your life-long contribution towards the development of the profession.
Thank-you David for bringing this research to our attention.
I would be interested to see how the individuals presented…. and whether it would have been possible to pick the dominant pain mechanism from the start…… along the lines of the research from Smart (2011 and 2012).
All the best